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Lack of NHS capacity and short staffing on maternity wards has been highlighted as a key theme of a national investigation into the deaths of mums and babies.

The probe chaired by Baroness Valerie Amos has outlined why mums and babies are still needlessly dying during childbirth after assessing problems at 12 NHS trusts. One of those trusts is Oxford University Hospitals NHS Trust where one mum told how she nearly died after her emergency C-section had to be delayed.

Lucy Crawford, from Bicester, needed three blood transfusions and her baby daughter had to be resuscitated after staff delayed giving her C-section over a weekend. The lawyer, now aged 38, had developed a serious condition, similar to pre-eclampsia, towards the end of her pregnancy in 2018 but maternity staff missed the signs despite her repeatedly raising concerns.

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Even once they realised what was wrong, staff put off emergency surgery for another 36 hours because it was a weekend and operating theatre capacity was limited. Lucy became dangerously ill and had to be put under general anaesthetic as doctors tried to keep her stable.

Lucy's daughter had to be resuscitated and spent two weeks in neonatal special care. She said: “My care was really disjointed and no one ever took overall responsibility. There was also a total failure to listen to me when I was trying to say something wasn’t right.

"Instead I was repeatedly told I simply had indigestion. If they had taken me seriously, and then acted quickly when they finally diagnosed what it was, everything we went through might have been avoided.”

Baroness Amos’s team has met with over 400 affected women and received input from over 8,000 people including mums, their relatives as well as NHS staff. She said: “It is clear from the meetings and conversations I have had with hundreds of women, families and staff members across the country, that maternity and neonatal services in England are failing too many women, babies, families and staff.”

The inquiry outlined six “emerging themes” that are still leading to poor NHS care despite numerous earlier inquiries into maternity scandals at trusts in the last decade. Two of them are workforce shortages and lack of NHS capacity.

When Lucy’s second daughter was born, in 2023, she had another negative experience when short-staffing on a postnatal ward meant her baby’s health issue was missed, so she also ended up needing to go into neonatal care. She said: “It compounds your trauma when the same service lets you down again.”

The interim findings from the National Maternity and Neonatal Investigation come as Baroness Amos continues to draw up a series of national recommendations to improve maternity and neonatal services. However some families have said it does not have enough power and are demanding a full statutory public inquiry.

Lucy feels the probe will struggle to tackle the “insurmountable challenge” of improving maternity services. She said: “There are so many issues and they are all so deeply interconnected – every single aspect of care is affected. There is no quick fix and it’s hard to see what the rest of the investigation will achieve, although it would be nice to feel hopeful it will lead to change.”

A spokesperson for Oxford University Hospitals NHS Trust said they had been reviewing Lucy’s care to see if there were opportunities to make improvements, after being first alerted about her concerns late last year. They added: "We are committed to providing the highest standard of care for all our maternity patients and their families.

“We are pleased that the feedback we receive from patients is positive overall, however, we recognise there is more we can do to improve and this remains a top priority.”